ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Receive assigned insurance verification requests (IVR’s) from data intake; call Health Plan to obtain benefit coverage levels and prior authorization requirements to determine payer reimbursement; submit required preauthorization/predetermination paperwork to payer
- Initiate contact with Health Plan and follow-up on benefit coverage requests and prior authorizations; identify and escalate issues as they may arise throughout the process
- Enter coverage levels and/or prior authorization requirements for assigned accounts in database (Alfresco)
- Review and correct data entry errors made by data intake team
- Review and work daily pending case reports to ensure prompt processing and closure of IVR’s and authorization requests
- Respond to simple, routine questions from physicians, hospitals, outpatient
- Determine if payer already in SalesForce database; if not, research payer on website to obtain demographic information and forward to senior team member for data entry
- facilities/ambulatory care centers, etc. regarding billing, coding procedures, and processes
- Follow HIPAA policies and procedures to ensure compliance
- Report changes/issues in coverage/reimbursement trends to management
PROBLEM SOLVING:
- Effectively identifies problems as they occur and takes appropriate steps to solve them in situations where the problem is not difficult or complex
- Refers complex, unusual problems to supervisor
DECISION MAKING/SCOPE OF AUTHORITY:
- Under general supervision, exercises some judgement in accordance with well-defined policies, procedures, techniques
- Work typically involves regular review of output by a senior coworker or supervisor
EDUCATION/EXPERIENCE:
- HS Diploma or GED
- Specialized skill training; certification may be required
- 2-5 years of experience in area of responsibility
- Basic understanding of Medicare, Commercial and Medicaid health plans a plus